R&R In The FASTLANE 182

Welcome to the 182nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

Fuller BM et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017. PMID: 28259481

• This study was called LOV-ED. Initiation of a mechanical ventilation protocol in the ED using a low tidal volume strategy, PEEP protocols, rapid FiO2 weaning, and head-of-bed elevation resulted in dramatic clinical improvement in the composite primary outcome: ARDS or ventilator-associated conditions; NNT = 14. And a secondary outcome, mortality, was also improved, NNT = 7. There is no way to account for all the confounders or other process improvements that may have also led to better outcomes, but the use of propensity analysis makes this association very believable. REBEL EM has a great deep-dive on this article.
• Starting lung protective ventilation in the ED is feasible, it influences ventilator settings in the ICU and reduces pulmonary complications. Implementation includes getting an accurate height to use for the tidal volume, minimal FiO2 to meet an O2 saturation greater than 90%, matching PEEP to the FiO2 according to the ARDSNet protocol, keeping the plateau pressure < 30 mm Hg and keeping the head of the bed at 30 degrees.
• Lung protective strategy has been around for more than a decade but continues to not be widely embraced particularly in the ED. This before and after study demonstrates that implementing a lung-protective strategy isn’t just feasible but is associated with decreased ARDS, increased ventilator and ICU free days and decreased mortality.
  Patients intubated in the ED without reactive airway disease should be ventilated with a lung protect approach. Implementation includes getting an accurate height to use for the tidal volume, minimal FiO2 to meet an O2 saturation greater than 90%, matching PEEP to the FiO2 according to the ARDSNet protocol, keeping the plateau pressure < 30 mm Hg and keeping the head of the bed at 30 degrees.
• Recommended by: Clay Smith, Salim R. Rezaie, Anand Swaminathan
• Read more: ER Vent Settings Save Lives (EM Topics), The Benefit of Lung Protective Ventilation in the ED Should be LOV-ED (R.E.B.E.L. EM)

Alshehri A, et al.Intravenous Versus Nonintravenous Benzodiazepines for the Cessation of Seizures: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Acad Emerg Med 2017. PMID: 28342192.

• A systematic review and meta analysis that looks at what to do when you have the seizing patient in front of you. Should you give your preferred benzo by the fastest means possible? Or establish an IV and administer via that route? The short answer provided by this study, is to give your benzo IM or IN. While seizures stopped sooner after IV administration, the additional time needed to establish an IV resulted in overall longer seizure time when administered via that method.
  While limited by the less than optimal studies which have been done on this topic, this is the best available evidence we have.
• Recommended by: Jeremy Fried

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Thoma B, et al. Individual Gestalt Is Unreliable for the Evaluation of Quality in Medical Education Blogs: A METRIQ Study. Annals of emergency medicine 2017. PMID: 28262317

• With the rise of free open access medical education, how can we judge a good blog post from a bad one? One answer is gestalt – subjective, qualitative impression. But can we rely on individual gestalt that a blog post is high quality? The authors found that individual ratings of 20 blog posts had poor correlation within the various levels of training – medical student, resident, and attending. But if at least 42 people evaluated a blog post’s mean gestalt quality, there was very good correlation among medical students, residents, and attending physicians. Think of it like ratings on Yelp or Amazon. Fans or haters will rate very high or very low, but the crowd tends to find a mean rating you can trust. It’s the same with medical blogs, but you need a crowd size of at least 42 to get a reliable rating.
• Recommended by: Clay Smith
• Read more: Can You Tell a Good Blog From a Bad One? (EM Topics)

Konstantinides SV, et al. Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. Journal of the American College of Cardiology 2017. PMID: 28335835

• There has been some thought that thrombolytic therapy for larger PE may improve functional outcome and dyspnea on exertion from chronic pulmonary hypertension, based in part on the MOPPETT trial. But this study says probably not. PEITHO studied lytics for submassive PE. This was the long-term follow up aspect of the study, and it found there was no mortality benefit and no change in dyspnea or pulmonary hypertension at about 3-years post-treatment in those who received lytics.
• Recommended by: Clay Smith
• Read more:  PEITHO – Long-term Follow Up (EM Topics)

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Kaufman J, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ 2017. PMID: 28389435

• A neat little RCT looking at the “Quick-Wee” method for speeding up clean catch urine sample collection in children aged 1 month – 12 months in the ED. The Quick-Wee method involves cold (refrigerated) sterile 0.9% saline, soaked into gauze and applied through cutaneous stimulation of the suprapubic area in a circular motion. The rate of voiding within five minutes of initial genital cleaning rose from 12% to 31%, a 19% difference in proportions equating to an NNT of 4.7 for the Quick-Wee method in order to induce voiding in one additional patient in five minutes. Probably worth a try for those parents who aren’t keen to wait around.
• Recommended by: Natalie May